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Define or be defined What is integrated behavioral health and primary care? The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health, substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, ineffective patterns of health care utilization. Peek, C. J., National Integration Academy Council. (2013). Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. In Agency for Healthcare Research and Quality (Ed.), AHRQ Publication No.13- IP001-EF.

Behavioral health Institutionalization (mid 1800s - 1950/1960) Inpatient care model - patients lived in hospitals and were treated by professional staff (used to be considered most effective way to care). Institutionalization welcomed by families and communities (e.g. Uncle Johnny) Deinstitutionalization (1950s on) A push for deinstitutionalization and outpatient treatment began (in part due to living conditions and development of antipsychotic drugs)it was believed that community-oriented care could help patients have a higher quality of life if treated in their communities In 1963, Congress passed the Mental Retardation Facilities and Community Health Centers Construction Act, which provided federal funding for the development of community-based mental health services.

The two pots of money

Model mastery Payment model Description Pros Cons Fee for Service (FFS) FFS system uses a retrospective payment where each item of service provided is reimbursed based on certain billing codes that are submitted as a claim to the health insurance company; behavioral health payments primarily come from a separate entity within an insurance company Behavioral health services can receive compensation for their mental health services Relegates behavioral health clinicians to deliver more traditional mental health interventions often independent of the team

Model mastery Payment model Description Pros Cons Modified Fee for Service Oftentimes a hybrid of FFS and non-ffs payments. For example, pay for performance (see below) and partial capitation. Increases the ability of PCMH to engage in some value-based rather than solely volume-based care. Still makes behavioral health its own service line and intervention rather than a part of the team

Model mastery Payment model Description Pros Cons Pay for Performance (P4P) P4P holds clinicians accountable for the outcomes their care delivers. Such initiatives aim to incentivize processes and outcomes of care Increases the likelihood that certain behavioral health conditions are addressed (e.g., depression) Payment may not be sufficient to support the behavioral health member of the primary care team

Model mastery Payment model Description Pros Cons Bundled Payments Bundled payments reimburse for a discrete course of treatment rather than paying for each discrete clinical interaction and procedure Supports more of the team approach to specific conditions Behavioral health often not considered as a part of the payment bundle

Model mastery Payment model Description Pros Cons Global Payments A global payment system, or a capitated system, pays a predetermined per person rate to healthcare organizations, regardless of the delivered services When behavioral health is a part of the service expectations through the global payment, there can be seamless and unfettered access to behavioral health; behavioral health becomes natural extension of primary care team Challenge associated with assuming risk for patients with behavioral health; practice change and transformation

Spending Pattern Conventional FFS Specialists 20.8% Ancillary 12.5% Emergency 3.7% Inpatient 22.6% Outpatien 18.3% Primary Care 4.6% Pharmacy 17.5%

Spending Pattern Value Based Specialists 19.3% Ancillary 11.5% Emergency 3.4% Inpatient 20.9% Primary Care 9.1% Outpatien 16.9% Behavioral 0.5% Pharmacy 18.4%

Isn t the second pie bigger? No. Total Cost PMPM Advanced Practices $479.30 Behavioral Health Payments $4.35 Total $482.85 Conventional Network Average $505.83 Risk Normalized Difference -4.54%

Comprehensive primary care is a high leverage investment Integrated BH is just another (important) aspect of comprehensive primary care Small part of the total health care budget Exemplars are performing very well; the question is how to scale this model through accelerated transformation.

An example of payment reform SUSTAINING HEALTHCARE ACROSS INTEGRATED PRIMARY CARE EFFORTS (SHAPE) 32

Sustaining Healthcare Across integrated Primary care Efforts A partnership between Collaborative Family Healthcare Association, Rocky Mountain Health Plans, Colorado Health Foundation, and University of Colorado School of Medicine Department of Family Medicine To test an alternative payment model to sustain behavioral health in primary care

The set up To test a different payment method to financially support and sustain behavioral health in primary care; To better understand the costs associated with integration and a global payment methodology for behavioral health and primary care; To test the real world application of a novel payment methodologies on novel primary care practices who have integrated behavioral health with the end goal to inform policy. The SHAPE project deployed a mixed methods evaluation collecting both qualitative (interviews and monthly calls with providers and staff and site visit notes) and quantitative (clinical and claims) data. The evaluation team assessed the value of integration and payment reform on overall healthcare cost and outcome trends in integrated practices with the main focus of understanding if a new model of payment changed the sustainability of integrating behavioral health into primary care. 34

Sunrise Mountain Family MidValley Foresight Primary Care Partners Axis Experimental Foresight Mountain Family Primary Care Partners Intervention MidValley Axis Sunrise

Defining the intervention Sufficient, non-encounter, non-volume based reimbursement to afford primary care providers the time and capacity required to perform evidencebased clinical interventions, as well as the asynchronous planning, panel management and coordination activities entailed in effective integrated care; Accountability for the total cost of care incurred by patients, supported by internal and external feedback reporting, with proportionate and progressive exposure to losses and bonuses for achieving prospective budget and quality targets; A material bonus opportunity for measured quality, independent of financial budget targets, for the purpose of continuous improvement, innovations and the development of stronger external connections with community resources. 36

A Tale of Two Approaches Component of Care Traditional Integrated Access Referral Point of Primary Care Scope of Service Mental Health Diagnoses Overall Health Function Scheduling Separate Shared Collaboration of Care Individual Provider Team Based Health Record Separate Shared Administrative Operations Separate Shared Payment Separate Global Communication Minimal Frequent & Timely Focus of Care Provider-Centric Patient-Centric Approach to Care Case by Case Population-Based Efficiency of Delivery Structure Fragmented &Inconsistent Coordinated and Aligned

Payment recommendations This is not about changing the way we pay for behavioral health; this is about changing the way pay for primary care that includes behavioral health Make sure the delivery setting is getting paid by keeping the patient healthy, not per patient visit (e.g. move as quickly as possible away from fee for service) Make sure there are incentives in place to encourage primary care clinicians to work with behavioral health (e.g. hold them accountable for certain behavioral health conditions)

Key steps 1) Consistently define your effort How can you pay for or measure what you have not defined? What is and what is not integration? 2) Calculate a baseline cost of your program (expenditure analysis) 3) Create global payments based upon defined practice budgets (see #2) for personnel, interventions and related infrastructure to create team-based, whole-person care (e.g. CoACH) Change payments to allow for behavioral health providers to not be trapped in a workflow designed to maximize volume-based payments, or pigeon holed into distinct physical and mental health coding categories 4) Consider at what level you intent to measure your effort Access? Cost? Improvement? 5) Tell your story (often) 39

Additional considerations How can the population be stratified by severity (e.g. SPMI vs mild/moderate)? How do payment models limit your ability to practice prevention? Measurement (e.g. how many more people were seen, at what cost, and where?) How is care financed to support model? How do payment models limit what can done in practice? What are the minimal training requirements/competencies based upon setting? How are social determinants factored in? How is information shared across the community? 40

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James Baldwin THOSE WHO SAY IT CAN T BE DONE ARE USUALLY INTERRUPTED BY OTHERS DOING IT